The incidence of hiatal hernia is not known (estimates range from 10% to 80%) and most doctors do not believe that it has serious sequelae.
However, some doctors believe that hiatal hernia is largely responsible (with the minor factor of incompetent lower esophageal sphincter) for acid and bile reflux into the esophagus. Over time this reflux can lead to Barrett’s esophagus (intestinal columnar metaplasia due mostly to bile), which can, if untreated, lead to increasing grades of dysplasia, which can, if untreated, progress with further deleterious changes to esophageal adenocarcinoma.
A more balanced view of the role of hiatal hernia and incompetent lower esophageal sphincter is this: when pressure builds up in the stomach, the properly positioned diaphragm largely resists this pressure, but the herniated diaphragm cannot do it nearly so well. Thus, to observe GER or GERD, a more incompetent sphincter is required when no hernia is present. Correspondingly, a less incompetent sphincter, which is more common, is all that is required, given a hiatal hernia, the bigger the hernia, the less incompetence being required.
Can hiatal hernia also lead to breathing disorders (especially during sleep, but also during waking hours), specifically hypoventilation and hypercapnia, and from there to increased anxiety and increased risk of panic attacks?
A PubMed search for “hiatal hernia” AND “hypercapnia” netted nothing.
A PubMed search for “hiatal hernia” and “breathing disorders” netted only a few references, the most relevant of which suggest that the hernia may be at least correlated to breathing disorders.
Here are some references:
Large hiatus hernia compressing the heart and impairing the respiratory function. Ueda T, Mizushige K.
[Respiratory and dysuric disorders in hiatal hernia].
In the period of 1973-1987 the authors followed-up 1053 patients with hiatal hernia with different types of a clinical course. Various respiratory symptoms (cough, attacks of asphyxia, etc.) were observed in 181 patients, dysuric symptoms (dysuria, urethral colics, etc.) were observed in 66 patients. Of this number 347 were operated upon. A positive effect was achieved in 36 of 41 operated patients with bronchopulmonary disorders and in 16 of 23 patients with dysuric disorders. Organic respiratory and urinary changes were undetectable before operation. The authors considered a possibility of the development of the vagosolar syndrome lying in the basis of the pathogenesis of the above disorders.
Interaction of sleep disturbances and gastroesophageal reflux in chronic laryngitis.
- 1Medical Department, Marienkrankenhaus, Marburger Strasse 85, 34127 Kassel, Germany.
A considerable percentage of patients with reflux laryngitis do not respond to conventional treatment with proton pump inhibitors or prokinetics. At the present time, the reasons for this are not well known.
To investigate whether nocturnal reflux associated with sleep-related respiratory disorders is the cause of refractory laryngitis.
The data from 227 patients (133 women, ages 18 to 75 years, body mass index 17.4 to 38.3, mean 32.1 kg/m(2)) with LG were analyzed retrospectively. All received laryngoscopy and gastroscopy. All patients initially received 40- to 80 mg omeprazole and underwent a follow-up laryngoscopy after 6 weeks. Of the patients, 202 showed a clear improvement, whereas 25 (11.1%) did not. All underwent 24-hour pH monitoring and cardiorespiratory polysomnography.
All of the patients showed laryngoscopic signs of LG. Of the patients, 102 (45%) had a hiatal hernia and 53 (28%) suffered from reflux esophagitis. Forty-two patients (19%) were found to have Helicobacter pylori in the stomach. Among the 25 patients who failed to respond to omeprazole, pH monitoring showed nocturnal acid reflux in 15 (60%). Twenty-four patients (96%) showed a sleep-related respiratory disturbance manifesting as pathologic snoring (16 patients) or obstructive sleep apnea (8 patients, respiratory disturbance index [RDI] 11 to 33, mean 16.3/h). All received nasal continuous positive airway pressure (nCPAP) treatment, 16 with constant mask pressure (4 to 12, mean, 5.6 mbar) and 8 with autoadjusting pressure. One patient abandoned treatment; the other 23 showed clear subjective and objective improvement after 3 months of treatment.
Even without pH monitoring evidence of nocturnal reflux, refractory LG is very often associated with sleep-related respiratory disorders and responds well to nCPAP treatment. Prospective studies are needed to clarify the details of this association.
Thoraco-abdominal pressure gradients during the phases of respiration contribute to gastroesophageal reflux disease.
- 1Division of Thoracic and Foregut Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA 90033, USA.
BACKGROUND AND AIMS:
Exaggerated pressure fluctuation between the thorax and abdomen during exercise or with pulmonary disease may challenge the gastroesophageal barrier and allow reflux of gastric juice into the esophagus. The aim of this study was to investigate the pressure differentials in the region of the gastroesophageal junction to better understand the relationship between the thoraco-abdominal pressure gradient and the lower esophageal sphincter (LES) barrier function.
We reviewed the esophageal motility and 24-h pH studies in 151 patients with a manometrically normal lower esophageal sphincter who did not have pulmonary disease, history of anti-reflux surgery, hiatal hernia, or ineffective esophageal motility (IEM). Intra-abdominal gastric and intra-thoracic esophageal pressure fluctuations with respiration were measured and the thoraco-abdominal pressure gradients were calculated during both inspiratory and expiratory phases of the respiratory cycle. Predictive factors for an abnormal composite pH score were identified by multivariable analysis.
An inspiratory thoraco-abdominal pressure gradient that was higher than the resting LES pressure was found in 27 patients. In 23 of these patients (85.2%) there was increased esophageal acid exposure (OR 13.5, 95% CI 4.4-41.8). An abnormal composite pH score was predicted by a high inspiratory thoraco-abdominal pressure gradient (P < 0.001), greater fluctuation between inspiratory and expiratory thoracic pressure (P = 0.023), lower LES resting pressure (P = 0.049) and a decreased residual pressure after a swallow induced relaxation (P = 0.002).
The gastroesophageal barrier function of the LES can be overcome during times when the inspiratory thoraco-abdominal pressure gradient is increased, leading to reflux of gastric juice into the esophagus. This implies that exaggerated ventilatory effort, as occurs with exercise or in respiratory disease, can result in gastroesophageal reflux.
Congenital Paraesophageal Hernia in a Cat.
- 1From the Dallas Veterinary Surgical Center, Dallas, TX (K.T.); and Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Veterinary Medical Center, Michigan State University, East Lansing, MI (R.G.).
A 3 mo old male domestic shorthair weighing 2 kg was presented for acute onset of anorexia, lethargy, paradoxical breathing, and a palpable mass effect in the cranial abdomen. Initial diagnostics and imaging suggested a pleuroperitoneal or hiatal hernia. Emergency abdominal exploration was performed, and a complex type II paraesophageal hiatal hernia was identified. The entire stomach, greater and lesser omenta, spleen, left limb of the pancreas, and the proximal segment of the descending duodenum were herniated through a discrete defect in the phrenicoesophageal ligament. After reduction of the herniated organs back into the abdomen, a phrenicoplasty, esophagopexy, and left-sided fundic gastropexy were performed. The cat recovered uneventfully from the procedure and was free of any signs of disease for at least 30 mo postoperatively. This is the first detailed report of the findings and successful surgical treatment of a complex congenital, type II paraesophageal hiatal hernia with complete herniation of the stomach, omenta, and spleen in a cat.
- [PubMed – in process]